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A recent article in the Atlantic explored gender and the intersections of adolescent development, medical care, and parenting. Through the experiences of young people, trans and gender non-conforming folks, families and researchers, the article explores the central question of how to balance providing young people the support (from family support and mental health services to puberty-blocking drugs, hormones and/or surgery) they need while keeping in mind that adolescence is a time of identity exploration, and there is a diverse spectrum of gender identities beyond cis and trans- over 50 different identities are listed on Facebook. The article has received criticism from some readers, often those in the trans/gender non-conforming community for the focus on people who “desist” or “detransition”. Needless to say, there are so many layers to unpack in this issue, but setting that aside for a moment, I want to bring forward the pieces I found poignant as a cisgender female, heterosexual, White parent and professional working in adolescent and school health.

One thing that stood out to me in the article was the central tension between fully affirming and accepting young people’s (whether it is your child, student, or patient) identity with the pacing of young people making medical decisions that impact them for the rest of their lives. From the perspective of a parent, I fully understand wanting to give your kids all of the resources they need to be successful. I also recognize the experiences of trans and gender non-conforming folks in the medical community, and moving away from any sort of gatekeeping or putting in place hoops to jump through in order to get care. Youth development practices came to mind while I was reading this article, particularly the tenants of Developmental Relationships, a framework created by the Search Institute’s research in what makes relationships powerful for young people. The elements are:

- Express care

- Challenge growth

- Provide support

- Share power

- Expand possibilities

Developmental relationships not only express care and provide support, but they challenge growth. We need both. Mental health, influences of peers and social groups and societal and cultural norms all contribute to the development of gender identity, and all of these layers need to be interrogated by young people as they figure out who they are. However, that nuanced and critical analysis of themselves and their culture by young people needs to happen in an environment where they are affirmed and supported.

A well-trained team of providers working in partnership with youth and families will lead to better outcomes.

Sharing power, particularly with regard to the medical community for trans and gender non-conforming young people is paramount. A well-trained team of providers working in partnership with youth and families will lead to better outcomes. Finally, expanding the possibilities for young people as they explore their identities, to me, is to continually challenge stereotypical gender norms and roles. This is something we talk about a lot in our family. Case in point- my 2 year old son loves to wear his big sister’s dresses. It is fascinating to see how this one clothing choice changes the way the world interacts with him. Yet, when he plays loud and rough he is “all boy”. We constantly challenge those gender stereotypes as they come up (which is almost everyday). Boys can wear dresses. Girls can have short hair. Boys can play with baby dolls. Girls can be loud and climb things.

Whether you like or dislike the Atlantic article as written, one thing that I think even critics can agree with is that the foundation of any healthy identity development must be affirmation, love and support. It stood out to me that many of the young people in the article were surrounded by affirming and supportive parents and had the means and ability to access medical professionals who also affirmed their identity. This is not the case for many young people in this country. We all can do our part to create a more affirming and loving society- in our homes, communities and institutions. Below are lists some actions I came up with, and would love to hear others from anyone reading this as well!

- Support statewide policies that make access to medical services for trans and gender-non-confirming youth available and affordable.

- Make sure your state department of education and school district has a non-discrimination and student rights policy that includes trans and gender-nonconforming students as a part of Title IX, as Federal guidance on the issue was rolled back by Attorney General Jeff Sessions and Education Secretary Betsy DeVos.

- Support your school to have an all-user bathroom and policies that allow students to use the locker room that aligns with their gender identity.

- Call students by their preferred pronouns. Let them wear clothing that makes them feel good.

- Ensure comprehensive sexuality education includes information and skill building around respect for people with different gender identities.

- Bring voices from the trans/gender non-conforming community into your classroom. Engage your school’s Queer Straight Alliance (QSA) and reach out to organizations run by and for folks in the trans and gender non-conforming community.

- Challenge stereotypical gender norms and tell the young people in your life you love them, for who they are, daily.

- Support and donate to organizations in your community that serve trans and gender non-conforming youth and families.

At-risk youth have strong negative Social Determinants of Health (SDoH), which include conditions in which you are born, grow, live, work and age. SDoH include biology and genetics, individual behavior, social environment, physical environment, and access of health services.

Supporting at-risk youth is of the utmost importance as they are less likely to have access to health care, health education, and formal sex education. Educating and equipping youth with personal safety, nutrition, and relationship skills, in a comfortable environment could be life changing, as at-risk youth are also more at risk for sexual violence.

A recent study conducted in Central Texas of youth enrolled in the Risk-Reduction Education about Abstinence, Contraception, and Health, or the REACH project (Wilson et al., 2018). 76 youth between the ages of 15-21 years, who were homeless, current or former foster youth, or youth who left high school prior to graduation made up the sample population (Wilson et al., 2018).

Across all groups (male, female, heterosexual and non-heterosexual), the most common topic that youth were interested in learning was Healthy Relationships and Personal Safety (Wilson et al., 2018). Overall, youth reported wanting to learn about these topics from a nurse/doctor or a teacher, reporting that it is difficult to learn about these topics from a family member (Wilson et al., 2018). The least preferred type of educators across all groups was a Faith Based Worker, while the mode of learning across all groups was the same, youth preferred to learn in a small group class setting (Wilson et al., 2018). In a surprising result, the least preferred mode of sexuality education was learning over technology, this included apps and text messaging (Wilson et al., 2018).

Supporting at-risk youth includes listening to their educational preferences, developing innovative programs and creating new ways to engage youth within the process. This does not stop or begin with sex education, it begins with supporting the child and the community. Keeping at risk students active, engaged in community activities, and informed on health risks and supports can begin in the classroom but needs to be continued once the students leave school. For example, relationships can be a difficult topic to cover in classroom and most learning opportunities about the topic are environmental, making out of school community supports a key factor (Wilson et al., 2018).

Triple Play delivers on the belief that whole child health fosters young people’s ability to gain diverse knowledge, skills, and protective factors that enable them to overcome barriers to wellness and positively impact their future health. Triple Play provides health promotion, which encompasses health education, health literacy and a range of social and environmental interventions designed to benefit and protect health and quality of life.

— Boys and Girls Clubs of America

An organization who has been working to help at risk student populations is the Boys and Girls Clubs of America, they have been implementing a program titled, TRIPLE PLAY: GAME PLAN FOR MIND, BODY AND SOUL, a program designed to support youth who are raised in areas with poor SDoH.

The Boys and Girls Clubs of America continue to run research on how well the program is working, more information on the program along with statistics and research findings can be found at the link below!

The #MeToo movement has shown the extent to which acts of rape, sexual violence and sexual misconduct permeate the lives of countless women, as well the people and institutions that allow it to perpetuate like an “open secret”. Last month, the news of allegations of sexual misconduct against Asis Ansari added a new dimension to the #MeToo discourse. There was a debate about whether the actions of Asis belonged in the same conversation as the actions of Harvey Weinstein or Larry Nassar. But folks working in the field of sexuality education knew that it did.

While I was consuming all of this in my news feed, I just kept thinking to myself, “This is why we need more comprehensive sexuality education in every school in every town starting from preschool through higher education!” According to the Guttmacher Institute, fewer than half the states require schools to include the topic of “avoiding coercion” as part of a sexuality education program and similarly, a majority don’t require discussion of healthy relationships. But teaching young people about healthy relationships is the primary prevention for sexual violence because it’s centered on breaking down gender stereotypes, setting healthy boundaries, communication, and that consent is more than just “not hearing no”.

There are states and school districts that are using this as an opportunity to strengthen laws and policies around sexuality education. The Sexuality Information and Education Council of the United States (SIECUS) has developed a toolkit to support educators to advocate for policies that support comprehensive sexuality education. They also created the partner #TeachThem movement to build on the awareness that #MeToo has brought to the need for stronger comprehensive sexuality education. But even states with strong policies struggle with implementation due to a lack of funding for professional development for teachers and administrators.

This is why I’m so proud to be supporting a school district with funding from Advocates for Youth to develop a sexuality education plan of instruction K-12 inclusive of policy, scope and sequence and training/professional development. Earlier this month we held a meeting with folks representing: education, public health and child welfare at the state level; school administrators; district staff; county public health; community based organizations that provide culturally specific sexuality education; university; LGTBQ rights; and sexual assault/violence prevention. The group came together to critique the first draft of a district sexuality education policy. We envisioned a policy that codifies instruction that is not just developmentally appropriate and science-based, but inclusive and trauma-informed. A policy where school level data are used to guide instruction, and teachers are enthusiastic and equipped to teach sexuality education through strong professional development and support from an incredible network of community partners. There is so much more work to do, but I left this meeting filled with energy and hope.

I salute these and other professionals, sexuality educators, young people, teachers, administrators and advocates across the country working to strengthen sexuality education. Our work has never been more important or needed.

Last week brought two experiences that showed the promise of policy to actualize a positive change to support young people. Suicide is the second leading cause of death among young people aged 15-24. Sexual minority youth are at increased risk of suicide attempts- in 2015 29% of LGB youth in the US attempted suicide in the last year, compared to 6% of their heterosexual counterparts (the Youth Risk Behavior Surveillance Surveydoes not ask about gender-identity).

Schools are a really important setting to build protective factors against suicide risk, identify struggling students early, and support those who have attempted re-enter school in a safe and supportive way. Cairn Guidance is currently funded by the Oregon Health Authority to support schools to develop and strengthen their protocols around suicide, and connect staff to an excellent online training called Kognito.

What message does it send to young people when their state, their government, tells them their right to love and marry who they choose is the same as everyone else’s? That they are valued. That they belong.

Last week, I sat around a table with representatives from a large school district in Oregon. We were working through an inventory to assess the presence and strength of their school protocols, identifying gaps and action steps to address the gaps. Every professional sitting at that table brought a different perspective to the ways in which students are supported. Strengthening the systems and protocols will have a direct impact on the experience of students in this district who are struggling, and how they can access support they need. But we also questioned: What are the broader, whole school, whole community approaches to creating school environments that are safe where young people feel valued and loved?

That’s where this week’s second policy news comes in. A study published in JAMA Pediatrics this week found that found that state same-sex marriage policies were associated with a 7% reduction in the proportion of all high school students reporting a suicide attempt within the past year. The effect was concentrated among adolescents who were sexual minorities. For gay, lesbian and bisexual students in particular, the decrease was more pronounced. Rates of suicide attempts decreased from 28.5 percent to 24.5 percent (a 14 percent reduction in suicide attempts). There was no change in states that did not legalize same-sex marriage before January 2015. The effect persisted for 2 years after legalization.

While there are limitations to the study, and the exact mechanisms by which legalization impacted risk of suicide attempt, these findings show the power of public policy to effect change on the lives of young people. One hypothesis is that marriage equality laws reduce stigma- an underlying factor. Reducing rates of attempted suicide were not reasons cited for passing marriage equality. But it makes sense. What message does it send to young people when their state, their government, tells them their right to love and marry who they choose is the same as everyone else’s? That they are valued. That they belong.

Having a sense of belonging is a key protective factor for a host of issues, like substance use, mental health issues, and even supports engagement in school. These early findings reinforce that all policies are health policies.